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Open Access Open Badges Research article

Age adjustment in ecological studies: using a study on arsenic ingestion and bladder cancer as an example

How-Ran Guo

Author Affiliations

Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan

Department of Occupational and Environmental Medicine, National Cheng Kung University Hospital, Tainan, Taiwan

Sustainable Environment Research Center, National Cheng Kung University, Tainan, Taiwan

BMC Public Health 2011, 11:820  doi:10.1186/1471-2458-11-820

Published: 20 October 2011



Despite its limitations, ecological study design is widely applied in epidemiology. In most cases, adjustment for age is necessary, but different methods may lead to different conclusions. To compare three methods of age adjustment, a study on the associations between arsenic in drinking water and incidence of bladder cancer in 243 townships in Taiwan was used as an example.


A total of 3068 cases of bladder cancer, including 2276 men and 792 women, were identified during a ten-year study period in the study townships. Three methods were applied to analyze the same data set on the ten-year study period. The first (Direct Method) applied direct standardization to obtain standardized incidence rate and then used it as the dependent variable in the regression analysis. The second (Indirect Method) applied indirect standardization to obtain standardized incidence ratio and then used it as the dependent variable in the regression analysis instead. The third (Variable Method) used proportions of residents in different age groups as a part of the independent variables in the multiple regression models.


All three methods showed a statistically significant positive association between arsenic exposure above 0.64 mg/L and incidence of bladder cancer in men and women, but different results were observed for the other exposure categories. In addition, the risk estimates obtained by different methods for the same exposure category were all different.


Using an empirical example, the current study confirmed the argument made by other researchers previously that whereas the three different methods of age adjustment may lead to different conclusions, only the third approach can obtain unbiased estimates of the risks. The third method can also generate estimates of the risk associated with each age group, but the other two are unable to evaluate the effects of age directly.

ecological study; age adjustment; direct standardization, indirect standardization, standardized morbidity ratio, arsenic; drinking water; bladder cancer